Marcelo Fernando Di Carli

BACKGROUND: Left ventricular ejection fraction reserve (LVEF-R), defined as stress EF minus rest EF, is a marker for high-risk coronary artery disease in patients undergoing positron emission tomography myocardial perfusion imaging, but its prognostic and diagnostic significance in large real-world populations remains incompletely defined. We aimed to analyze the association of LVEF-R with mortality and high-risk obstructive coronary artery disease in a large multicenter cohort. METHODS: We analyzed 34 976 patients from 13 sites who underwent gated rest and vasodilator stress positron emission tomography myocardial perfusion imaging from the Registry of Flow and Perfusion Imaging for Artificial Intelligence with PET. Associations between LVEF-R and all-cause mortality and cardiovascular death were assessed using multivariable Cox regression models. In a subset with invasive coronary angiography (n=6843), the relationship between LVEF-R and angiographic disease was evaluated. RESULTS: A total of 9392 (26.9%) patients had an LVEF-R5%, adjusted hazard ratios for all-cause mortality were 1.20 for LVEF-R 0% to 5% ([95% CI, 1.13–1.28]; P P P <0.001). A negative LVEF-R was also associated with high-risk coronary artery disease, including left main and 3-vessel disease. CONCLUSIONS: LVEF-R is an independent predictor of mortality, with a graded association between impaired reserve and adverse outcomes. A negative LVEF-R identifies patients with a higher likelihood of multivessel or left-main coronary artery disease, supporting its role as a clinically relevant marker of high-risk disease.

To learn how to use stress myocardial perfusion imaging to differentiate ischemic from nonischemic cardiomyopathy. To learn how to protocol exams to assess the extent and severity of ischemia and viability. To learn how to recognize patterns of myocardial viability. To learn how to integrate ancillary information into ischemic/viability exams to guide management.

To learn how to use PET imaging to exclude infection or inflammation. To recognize imaging patterns that may indicate infection rather than inflammation. To learn how to integrate correlative imaging findings into the interpretation of PET images. To learn how to use PET imaging to guide management.

To understand the fundamental principles of positron emission tomography (PET) technology and its application in cardiac imaging. To recognize the advantages of PET imaging, including its quantitative nature, superior sensitivity, and higher spatial and temporal resolution, compared with other nuclear modalities. To learn about the integration of PET with computed tomography (CT) and its impact on cardiovascular imaging. To comprehend the process of positron emission, annihilation, and the detection of γ-rays in PET imaging. To explore the main clinical applications of PET in assessing myocardial perfusion, viability, metabolism, and innervation.

To learn how to recognize coronary microvascular disease in the absence of obstructive epicardial coronary disease. To learn how to identify coronary microvascular disease states and patient groups. To appreciate prognostic significance of microvascular disease.

To recognize normal positron emission tomography (PET) imaging appearances after heart transplantation. To learn how to integrate myocardial perfusion imaging, left ventricular (LV) function, and quantitative blood flow to ascertain the presence of coronary allograft vasculopathy (CAV).

To learn how to recognize a normal myocardial perfusion study. To recognize common patterns of myocardial perfusion imaging for one, two, and multivessel diseases. To learn how to quantify the extent and severity of myocardial ischemia and scar. To recognize artifacts from different radiotracers that may mimic coronary artery disease. To understand how to integrate ancillary information (e.g., rest and stress LV function, coronary artery calcium, and myocardial blood flow) to make an accurate diagnosis. To recognize how to differentiate predominantly obstructive coronary artery disease from coronary microvascular disease.

To understand the complexities of cardiac toxicity arising from chemotherapy and radiation therapy through detailed case studies. To emphasize the importance of early detection and comprehensive management of cardiac toxicity to improve patient outcomes. To equip healthcare professionals with advanced imaging techniques and clinical observations to identify, monitor, and mitigate cardiac toxicity in patients undergoing cancer therapies.

To learn about emerging applications of molecular imaging with positron emission tomography (PET) in cardiovascular disease. To understand the potential applications of PET in the diagnosis and management of patients with cardiac amyloidosis. To learn about the potential utility of PET in the diagnosis of myocarditis. To learn about the potential utility of novel radiotracers for PET imaging to assess thrombosis, fibrosis, calcification, and inflammation in cardiovascular disease.

To recognize and develop skills to troubleshoot artifacts caused by incorrect emission-transmission alignment, patient or cardiac motion, and other sources of attenuation correction errors. To recognize normal variants associated with different radiotracers on myocardial perfusion PET imaging. To develop skills to perform quality control of PET images, verify accuracy of time activity curves, and quantitative data.